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There’s a lack of unanimity in what the best methods are for treating prostate cancer and how to decide which treatment method is optimal for a given patient, so investigators study nonclinical factors of prostate cancer treatment patterns to form correlations.
In a recent study published in Urology Practice,¹ Lillian Y. Lai, MD, and co-authors examined the relationship between commercial prices for prostatectomy treatment and use of prostatectomy among younger, privately insured men with prostate cancer. Lai is a Society of Urologic Oncology fellow at University of Michigan, Ann Arbor.
While prostate cancer is the most common non-skin cancer and the second leading cause of cancer death among men in the United States, the majority of men diagnosed with prostate cancer actually die with the disease rather than of it. The key is to differentiate the two. The other tricky part is that there are a lot of different management options available, each with its own tradeoffs. When the counseling urologist makes a management recommendation, he or she takes into account the patient's preferences, cancer severity, baseline health status, life expectancies, and other factors to make sure that the recommendation fits with what the patient cares about.
Some prior studies have shown that non-clinical factors such as financial incentives may also play a role in prostate cancer treatment pattern. Since there is a certain degree of discretion allowed in the context of early prostate cancer management, where a lot of times there is no one definitively right answer, we wanted to see if commercial prices of prostatectomy were associated with management selection. Using private insurance claims data, we performed a retrospective cohort study of the management of 38,000 privately insured men aged 64 or younger, who were diagnosed with prostate cancer between 2010 and 2016 in the U.S. We wanted to see how management selection differed depending on the average price paid to a urologist in that specific health care market for doing a prostatectomy. The reason why we chose to focus on the commercial space is because prices in the commercial space are negotiated and vary a lot more than in the Medicare space where prices are fixed and regulated. This wider range of prices allowed us to examine if urologists practicing in higher-paying markets were more likely, less likely, or equally likely to select treatment and, specifically, to select prostatectomy compared to urologists practices in lower-paying markets.
The first finding was that the use of any treatment decreased by 16% over the study period, and that is expected likely because of increasing acceptance of active surveillance. What will probably be surprising to the reader is that patients managed in markets with higher average prices for prostatectomy were not more likely to undergo treatment. Instead, we found that for every $1000 increase in the commercial price of prostatectomy, the use of any treatment actually decreased by 7%. Moreover, the use of prostatectomy was not associated with commercial prices. One interpretation is that urologists in the markets that paid more for performing a prostatectomy did not preferentially recommend treatment, or prostatectomy in particular. We often expect higher prices to drive utilization, but this was not this case in this specific context.
Our reassuring findings tell us that financial incentives don't always drive up utilization. They also highlight that the relationship between price and utilization is complex and needs to be examined with dedicated studies for different contexts. However, this was also one just side of the equation. We were not able to look at how commercial prices translated into patient-side factors like out of pocket costs, which could play an important role in management selection. Ultimately, I think the key is to not get rid of financial incentives. I don't think that's possible. Rather, we should align financial incentives so that we can promote what suits the patients best, both in terms of cancer outcome and patient preferences.
I would say the take-home is that, on average, urologists were not motivated by higher prices of prostatectomy to select treatment in the commercial space. One actionable item for the practicing urologist is to keep in mind the financial toxicities associated with each treatment option, and they should be open to discussions with their patients.
1. Lai LY, Kaufman SR, Oerline MK, et al. Commercial prices for prostatectomy and treatment among younger, privately insured men with prostate cancer. Urol Pract. Published online August 20, 2021. doi:10.1097/UPJ.0000000000000252